Mommy Wars: The Prequel

Ina May Gaskin and the Battle for at-Home Births

Gaskin assisting a woman at the Farm, Jane Montanaro, during a delivery.Credit
Elinor Carucci/Redux, for The New York Times

One Monday morning last spring, Ina May Gaskin got into her golf cart and drove it down the dirt road away from her home on the Farm, a community of 175 residents on a former commune in rural Tennessee that her husband started in the 1970s. She pulled up to the community center, where she would be teaching a class on delivering breech babies. The class was part of a weeklong seminar Gaskin and her fellow midwives were offering to an eclectic group: nurse-midwifery students attending for college credit; a Boston-area family-practice doctor; midwives from around the country; and one, from Australia, who went by the one-word moniker Macca. They had traveled to this corner of southern Tennessee to learn from the founding mother of the natural-birth movement.

Gaskin began her presentation. She told the students that “at first, we brought breech pregnancies to the hospital, but we found after a while that we could deliver them here just fine. Footling breeches, which are thought to be the most difficult, in our experience, they often just slid right out.” Gaskin, who is 72, has the spry, almost Seussian presence of someone much younger. Her gray hair, trimmed since the days when she wore it in thigh-length braids, was loose and a bit wild, and she wore jeans, gardening shoes and a homemade jacket.

Gaskin, a longtime critic of American maternity care, is perhaps the most prominent figure in the crusade to expand access to, and to legalize, midwife-assisted homebirth. Although she practices without a medical license, she is invited to speak at major teaching hospitals and conferences around the world and has been awarded an honorary doctorate from Thames Valley University in England. She is the only midwife to have an obstetric procedure named for her. The Gaskin Maneuver is used for shoulder dystocia, when a baby’s head is born but her shoulders are stuck in the birth canal.

Gaskin cued up a video of a birth that took place in the 1980s. The couple, Judy and Brad, had traveled to the Farm from another state because their midwife couldn’t deliver their breech baby vaginally.

On the video, after five hours of pushing, Judy’s son emerged buttocks first, his tiny scrotum swollen from the pressure. Judy made increasingly urgent sounds — something between a Tuvan throat singer and a squawking chicken — as the buttocks inched out.

Gaskin paused the video. “The main danger with breech babies is that the head, the largest part of baby, is last to come out, so it may get stuck,” she told the students. “If the baby has been delivered to the umbilicus, you have five or six minutes before hypoxia sets in, but you don’t want to pull on the head if you can’t see the neck for fear of injuring the baby,” Gaskin said.

She restarted the video to show how that situation could unfold. Judy’s baby had been born up to his chest but his arms were caught alongside his head inside his mother’s body. On the DVD, a younger Gaskin, wearing a sleeveless dress, moved without a hint of nervousness. She rotated the baby’s torso vigorously to loosen it from Judy’s body; one arm emerged, but Gaskin was unable to reach in and grab a shoulder. The Tuvan throat sounds escalated.

Gaskin let the baby, half-born, hang out of his mother and dangle off the side of the bed. Using the weight of his body to traction his head into a better position, she pulled him out with a rush of bloody fluid. The boy looked a little limp, but after a vigorous rubdown and some gulps from an oxygen tank, he gave a cry. Minutes later Judy called out joyfully to another Farm midwife “Pamela, we have a baby!”

I first learned about Gaskin when I became pregnant last year. In my Brooklyn neighborhood, her books on birth are a standard part of the pregnancy canon, and I was given “Ina May’s Guide to Childbirth” and two copies of “Spiritual Midwifery” by three different friends. Now in its fourth edition, “Spiritual Midwifery” is a heady dispatch from the Farm’s midwifery practice around 1975. It tells of how Gaskin and other women discovered that birth could be a euphoric experience, a way of accessing a uniquely female power. In first-person anecdotes of births — “I began to rush and everything got psychedelic” is a typical description — the book shows vaginal, unmedicated birth to be an unparalleled opportunity for transcendence and communion. It has been translated into six languages and sold well over half a million copies.

I viewed the book with equal parts fascination and trepidation. Gaskin’s insistence that birth is a normal life experience, not a medical event to be feared, was a welcome balm to the care I was receiving at a traditional OB/GYN practice at a major New York City teaching hospital, where my healthy pregnancy seemed to nonetheless present a set of potential problems to bang down like Whac-a-Moles. But it was hard to imagine not only getting through birth without pain medication or whining, as Gaskin prescribes, but also laughing joyously, as a hippie woman in “Spiritual Midwifery” is pictured doing as her baby crowns. The very idea of natural childbirth contained within it the possibility of an “unnatural” birth, a way to fail.

Since the 1970s, Gaskin and the other midwives at the Farm have attended an estimated 3,000 births of women who live on the property, are from the local Amish community or have come to the Farm to give birth because they have read Gaskin’s books. Approximately 2 percent of them have ended up with C-sections, and none have labored under epidural anesthesia save for one “princess,” Gaskin told me, who rented white leather furniture for her birthing cabin and ultimately had to be taken to the hospital for pain relief.

Unmedicated home birth is being chosen by a growing minority of women. Between 2004 and 2009, giving birth at home increased 29 percent. Most of this rise is among white women. Recent pregnancy documentaries like “Pregnant in America,” “Orgasmic Birth” and “The Business of Being Born” — all of which feature Gaskin — present hospital birth as profoundly disempowering to women.

Currently about one-third of all American babies are delivered surgically. Most U.S. hospitals require labor to be artificially induced if a woman goes one to two weeks past her due date. There are also often deadlines for the length of time a woman may be in labor before surgery is required, and many doctors will not perform a vaginal delivery after a previous Caesarean.

Gaskin and many of her fellow midwives have no formal medical training, and the fact that they have good outcomes even with births that obstetricians consider high-risk — breeches, big babies and vaginal births after C-section or VBACs — is evidence, she says, that for most women less interventionist care is better.

In Gaskin’s experience, many women do not follow the labor curve that hospitals generally require of dilating approximately one centimeter per hour, and some women’s pregnancies go to 43 weeks without consequence. “Some women are stuck at two or five or seven centimeters for hours, then quickly they move several centimeters,” she said. She has found that upright positions, dim lights, eating and drinking and fewer vaginal exams speed women’s labor — none of which tend to be encouraged in a hospital.

Of course, comparing the Farm to hospitals is of limited value. Many hospitals deliver at least as many babies in a year as the Farm midwives have delivered in three decades. Women who give birth at the Farm are self-selected, and midwives screen them further, eliminating, for instance, women with complicated medical histories. Hospitals would undoubtedly have better outcomes if all pregnant women arrived in excellent health.

Nonetheless, Gaskin’s outcomes are compelling. Is it actually safer for a low-risk woman to give birth outside of the medical establishment, as Gaskin claims? In 2011, ACOG acknowledged that “the absolute risk of planned home births is low” but cited a meta-analysis of 12 home- and hospital-birth studies, called the Wax Paper, which reported a two-to-three-times-higher risk of neonatal death in home births than in hospital births. But critics have raised questions about the Wax Paper’s methodology; the study included unplanned accidental home births, for instance. Natural-birth advocates point to studies in countries where home birth and midwifery are part of mainstream medical care — in the Netherlands, 30 percent of births take place at home — which show home birth to be equally safe for the baby.

I went to Tennessee to meet Gaskin when I was five months pregnant. The Farm has the sleepy feel of a utopian community post-fervor, a slightly ruined idyll on 1,750 acres of forest. One paved road connects a network of dirt roads where trailers, solar-powered permaculture huts, a geodesic dome and regular suburban houses coexist.

Gaskin hadn’t planned to become a midwife. In 1968, having returned from the Peace Corps, she was living in San Francisco with her husband and young daughter and teaching English. She and her husband were spiritual seekers and tried LSD a few times, in hopes of “opening the doors of perception,” she told me.

Ina May and her husband went to hear Stephen Gaskin, a professor at San Francisco State College who held a weekly session called Monday Night Class, where young people processed their acid trips. “He was a little older, very charismatic and extremely sure of himself, and he could kind of speak to what was on people’s minds,” Ina May recalled.

Reed thin and over six feet tall, with long stringy brown hair and a beard, Stephen Gaskin opened class with a lecture, delivered cross-legged, drawing on geometry, Taoism or the New Testament, and then took questions. Gaskin was also married with a young daughter, and soon the two couples became involved in what was called a “four-marriage.” The relationship settled down to just Ina May and Stephen in the early 1980s.

Eventually, Stephen Gaskin’s audience grew to thousands and in 1970 he announced he was taking Monday Night Class on the road. Around 250 of his followers decided to join him in a bus caravan. Ina May, then 29, and nine other women on the trip were pregnant. The birth of Ina May’s first child had been traumatic. She was strapped down and given an episiotomy and a forceps delivery, standard hospital protocol at the time. Other women also had bad birth experiences and wanted to avoid hospitals. They passed around a Mexican midwifery manual and agreed to support one another in labor. Gaskin attended her first birth in a bus parked at Northwestern University, where Stephen Gaskin was speaking. Her main method initially was to “just be nice to the women.” After a couple of months, an obstetrician outfitted Gaskin with syringes and clamps and taught her basic emergency techniques. During the five-month trip, there was one death: Ina May’s son, born prematurely.

The participants in the caravan settled in Summertown, Tenn., in 1971. They took a vow of poverty and veganism and lived communally. Birth was a revered “sacrament.” Ina May and five other women ran a midwifery practice delivering babies of the community’s 1,200 members and nearby residents. Members built latrines, acquired horses and tractors and plowed meadows. They opened a soy “dairy” and a sorghum mill and started a book-publishing company. (Although the land is still communally owned, the Farm largely embraced capitalism in the 1980s, a traumatic event known as “the changeover.”)

The progenitor of the modern natural birth movement was a British obstetrician named Grantly Dick-Read. In his book “Childbirth Without Fear,” published in 1942, he argued that the pain of birth was primarily a result of social attitudes. Dick-Read was in part hoping to persuade working women to come back to the home and have more babies. He said that non-Western women, free from negative ideas about labor, gave birth more easily, and he recommended using fewer medical interventions.

Photo

Ina May with Stephen Gaskin in 1971.Credit
Gerald Wheeler

The ideas in “Childbirth Without Fear” overlapped with the Farm’s back-to-the-land ethos and with Stephen Gaskin’s brand of spirituality, which focused on the importance of group energy and being “unafraid.” Ina May and the midwives believed that a woman’s body would open more easily when the energy in the room was relaxed and she had sorted out her fears. The midwives saw themselves as putting birth back in women’s hands and showing them their true power.

But for much of history many feminists have come out on the side of fleeing from nature, not embracing it. In the early 1900s, feminists played a significant role in moving birth out of the domain of midwives and the home and into the hospital. In 1915, a group of suffragists, professionals and housewives formed the National Twilight Sleep Association to lobby for access to scopolamine, an amnesiac that when paired with morphine allowed women to go into labor and forget the experience afterward. In retrospect, twilight sleep looks barbaric; women on the drugs thrashed violently and were often hooded or placed in cage-beds while they labored. But many women demanded it, staging meetings where they testified about the benefits of twilight-sleep birth: shorter, less painful labors, better breast feeding, fewer forceps deliveries and an easier recovery.

In the 1970s when Gaskin began advocating for natural-birth options, she found herself at odds with feminists who were focused on getting women into the workplace and out from under the constraints of family. She was even booed off the stage in 1975 by a Yale feminist group. Some feminists, like the theorist Shulamith Firestone, hoped ardently for the day when human reproduction would be handled completely by machines.

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“Simone de Beauvoir said that the act of creating a baby is not volitional, so it’s basically not worth anything,” Gaskin told me. “The woman is just a passive instrument of biology. The idea then was that biology was not destiny, and we should transcend it.” But, Gaskin said, “having a female body — the ability to bring forth life — is something you could be grateful about, not repulsed by.”

Gaskin says that because midwife-assisted home birth is illegal in many states and hospital birth comes with restrictions, many women are de facto coerced into surgery or other interventions they don’t need. For Gaskin, choice in birth remains a realm of reproductive freedom that mainstream feminism, until recently, has foolishly ignored. She thinks that women should seek not just the freedom to decide whether or not to have a baby, but how to have it.

At the end of the breech-birth presentation, Gaskin got a call from another Farm midwife, Pamela Hunt, who had just delivered the baby of a woman who was staying at the Farm.

Gaskin headed to her birthing cabin. Inside, she found Hagino Hargis, who was 28, naked on a wicker bed with her tiny daughter at her breast under a heating blanket. The baby’s skin, still bluish, had a fine covering of down and was streaked with her first bowel movement. Tiny veins were visible through translucent aquatic eyelids. Her cord, twisted like a fiber-optic cable, was still attached to the placenta, which bubbled lightly in a bloodied salad bowl next to Hargis. Neil Young’s “Only Love Can Break Your Heart” played.

Hargis had driven from Kentucky with her husband, 3-year-old son and mother the previous week as she neared term. Her primary midwife was Hunt, and Gaskin planned on attending the birth. But after a week of going for walks, baking cakes and painting a labyrinth to meditate on during labor, Hargis had given birth very quickly. Hunt barely had time to get her gloves on when she arrived and found Hargis on her hands and knees, about to deliver.

“I was going to call you,” Hargis said apologetically when Gaskin came in, “but I just wasn’t sure it was the real thing because the contractions stayed far apart.”

“Did you decide about the antibiotics?” Hunt asked Hargis and her husband.

Hargis looked uncertain. In hospitals, babies’ eyes are routinely covered with antibiotic ointment to prevent infection that can be passed through the birth canal. In most states, the procedure is required by law. Farm midwives also recommend using the ointment — they know that some infections can be asymptomatic and they think the ointment is harmless. Some women don’t want to use it, however, because they have concerns about antibiotics and because the ointment temporarily blurs the baby’s vision and they think it interfers with bonding. The midwives then advise of the risks and let the woman decide. Hargis had tested positive for bacterial vaginosis. “What do most people do?” she asked Hunt. “Usually, it’s a 50-50 split,” Hunt told her. “But most people don’t test positive for B.V. You don’t want her to get an infection — if it happens, it’s a bad situation.”

OB-GYNs are very vulnerable to lawsuits. According to the Physician Insurers Association of America, they pay the most in damages of any medical specialty. The charge frequently leveled against practitioners is that they did not offer a medical intervention or did not offer it early enough. In a hospital’s risk analysis, it makes sense for many babies to have their vision briefly, sometimes unnecessarily, blurred to prevent a single case of blindness, or for a certain number of women to undergo unnecessary C-sections to prevent a single neonatal death.

Lawsuits aren’t an issue in Gaskin’s world. Her midwifery clinic has never purchased malpractice insurance or been sued. For years, when the commune was a true collective, she did not even accept payment for attending births. Farm midwives give intimate intensive prenatal care and have a high degree of trust with their patients. That’s why, Gaskin said, in 2006 when a breech baby she delivered became temporarily stuck and suffered permanent neurological problems, the parents did not sue. “We thoroughly discussed the issues, and they didn’t see a reason to be punishing,” Gaskin told me.

Midwifery was outlawed in some states as an independent profession at the turn of the century. Soon after, it was reinvented as an extension of a nursing degree, under the management of obstetrics. Today certified nurse midwives largely practice in hospitals and generally rely on obstetricians to grant them privileges. In 1982 Gaskin and other midwives created an organization, called Midwives Alliance of North America (MANA). Later, some members helped found the North American Registry of Midwives, which credentials midwives who haven’t necessarily been trained in medical institutions and aren’t beholden to their priorities. The registry, whose accreditation office is in a trailer on the Farm, grants an alternative certification and title — certified professional midwife (C.P.M.) — in the 27 states where the practice is legal.

When I visited the Farm, Gaskin was planning to travel to testify at the trial of a C.P.M., Karen Carr, who delivered a breech baby in a home in Virginia who died. Carr lived and practiced in Maryland, but Virginia requires a license in addition to certification, and because Carr didn’t have one, she was charged with involuntary manslaughter. (She pleaded guilty to lesser charges.) I pressed Gaskin about the case. Wouldn’t that particular baby have been better off in a hospital? She conceded that his life would have been saved but said that hospital birth comes with its own risks. “What bothers me are all the cases of women or babies who die due to unnecessary C-sections or postoperative infections or hospital errors,” she said, pointing to cases in the U.S. and Canada in which women died from complications from elective repeat C-sections. She says that when something goes wrong in a home birth, critics use it as evidence that home birth is dangerous, but when women die from embolism or hemorrhage after surgery, people don’t attack hospitals. “No one ever says those women were selfish for giving birth in a hospital, and no one ever blames the concept of a hospital birth,” she said.

Gaskin’s ideas about a less medicalized environment being conducive to labor made sense to me. But I wasn’t comfortable with any risk, however small, of something going wrong at a home birth, and I thought I might want pain relief. So midway through my pregnancy I switched from my obstetrician to a certified nurse midwife in a well-regarded New York hospital.

When I reached my due date, an ultrasound estimated that my baby weighed 9.4 pounds. I didn’t have gestational diabetes and had gained an average amount of weight, and fetal tests showed my baby was thriving. But the baby’s estimated size, combined with the fact that he hadn’t yet descended into my pelvis, worried my midwife.

She wanted the baby out by 41 weeks, and to my surprise, she suggested I consider going straight to surgery without labor. She sent me to be evaluated by a doctor she worked with. “One way or another, this baby will be a C-section,” he said.

I wanted to avoid induction or surgery, so eight days postdate, I drank castor oil, said to be a homeopathic labor inducer, and it worked. I was admitted to the hospital 12 hours later, four centimeters dilated. At the hospital my water broke, and I dilated another centimeter. But after two more hours without change, I was told I wasn’t progressing. The midwife pressed for a C-section, saying if I continued to labor I risked the chance of infection or shoulder dystocia. Bigger babies are at a greater risk for this complication, which in rare cases results in stillbirth or injury to the baby. It’s impossible to predict which babies will get stuck — average-size babies get caught, too — but when they do, it can be terrifying. Shoulder dystocia is also a major cause of obstetric lawsuits.

ACOG’s report about shoulder dystocia acknowledges that once a baby is thought to be big, practitioners are more likely to diagnose “failure to progress” or recommend surgery.

My son’s heart rate was strong, and I wanted to keep laboring. It was hard to make my case, though; I had been up all night and was hungry — in most hospitals women are prohibited from eating while in labor in the rare event that they might need general anesthesia. The midwife told us, “You don’t want to wait until the baby shows signs of distress — at that point it’s too late.” I negotiated for two more hours, made no further progress and then, under pressure, agreed to surgery. It was the kind of coercion by dint of not offering any other options that Gaskin talks about.

I was laid down with my arms on planks, a sheet dividing my head from my lower body. I was given a shot of spinal anesthesia, which caused me to shake — a common side-effect, although I didn’t know it at the time — so hard that my jaw would be sore for weeks. I felt a raw ache as my belly was cut. My husband was brought into the operating room; he saw blood on the floor and my shaking, and he felt terrified. He tried to reassure me. Soon, we heard the cry of our son, and he was handed, wrapped in a blanket, to my stunned husband. I couldn’t see the baby clearly because I couldn’t hold my head still. My husband couldn’t focus on the baby because he was worried about me. Then the anesthesiologist gave me a shot — “it will put you out just for a bit,” she said, and it did.

About 20 minutes after I woke from surgery, still shaking and out of it, I got to hold my son. He was alert and impossibly beautiful, with a single dimple and eyes open wide as satellite dishes, receiving everything.

Later, when I sat him up on my lap, his head dropped somnolently forward and he curled into a ball. It was the position he held inside my body and, still narcotized and sluiced with postpartum hormones, I cried in recognition and sorrow. We had grown together over 10 months, continuously shifting shape in response to each other, sharing every flight of stairs, dance party, bad mood. Having him cut out of my body felt like a rupture, and now I was too physically wrecked to even lift him from his bassinet.

My diagnosis — arrested dilation or “failure to progress” — is estimated to account for approximately 60 percent of American C-sections. In Gaskin’s practice, the failure-to-progress diagnosis doesn’t exist. When we discussed my birth story, months later on the phone, she told me she thought a bath, a nap, a snack, some encouraging words — or just a chance to labor without the threat of various catastrophes hanging over my head — might have kick-started my labor. Who knows if any of that would have worked, but I wish alternatives had been offered to me before surgery, because neither my son nor I were in any immediate danger. The most important thing to me is that my son emerged healthy. Still, I would like to have been more present for his arrival and in better shape during his first weeks, when just rolling over or sitting up hurt, and I worry about the risk for serious complications — uterine rupture, hysterectomy, endometriosis — I now face in any future pregnancies.

Yet I would still not choose to go to rural Tennessee — more than an hour from a top-level N.I.C.U. ward in Nashville — to be able to have more of a say in how I give birth. I wouldn’t even choose to have a do-over in my apartment, 10 minutes from a hospital. And although I like aspects of the home-birth experience, I’m put off by some of the dogma that can accompany the movement. In their rush to defend unmedicated births, natural-birth advocates sometimes fetishize them, saying for instance that the first moments after birth present a unique opportunity to bond that is forever lost when the mother’s and baby’s systems are flooded by anesthesia or other drugs. “The Business of Being Born” shows an image of a baby screaming alone in a hospital bassinet as a narrator intones: “When chimpanzees give birth by C-section, they don’t take care of their babies. It’s that simple.”

It’s not that simple, of course, and it is unfortunate that the choices and the rhetoric around birth — like many of the choices and rhetoric around motherhood in general — are so polarized. It should be possible both to have a baby in a place that doesn’t have financial and legal incentives to medicalize a low-risk pregnancy and to still have immediate access to top-level care if it’s needed. It shouldn’t be necessary to leave the medical establishment entirely to give birth vaginally to a breech baby or after a previous Caesarean. It should be possible both to acknowledge that something real was lost in the way my baby was born and to know that this loss is finite; there is not one pure route to authentic motherhood. Eight months with my son have offered ample evidence that there is not only one opportunity for joy.

Correction: May 27, 2012

An article on Page 18 this weekend about the home-birth movement misspells a kind of throat singing to which the noises made by a woman in labor are compared. It is Tuvan — from the Tuva region in Siberia where the singing is practiced — not Tuvian.